5816
                                        CHESS


                                  A Community Health

                                         and

                              Environmental Surveillance

                                        System
                Wilson B.  Riggan, Douglas  I. Hammer, John F. Finklea
                 V. Hasselblad, Charles R. Sharp, Robert M. Burton
                                   and Carl M. Shy
                        Presented at Sixth Berkeley Symposium
                     on Mathematical Statistics and Probability
                          Biology - Health Section, Part III
                                 Monday, July  19, 1971
                                 Berkeley, California
                         Division of Health Effects Research
                       National Environmental Research Center
                           Environmental Protection Agency
                    Research Triangle Park, North Carolina  27711

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CHESS INTRODUCTION

The Community Health and Environmental  Surveillance System (CHESS) relates
community health to environmental quality.  CHESS, consists of a series
of epidemiologic studies in sets of communities representing consistent
exposure gradients for common environmental pollutants.  The keystone
of the CHESS program is the coupling of sensitive health indicators to
comprehensive environmental monitoring  in sets of communities representinq
a consistent pollutant exoosure gradient, thus allowinq temnoral and
spatial replications of dose-response studies.

EPA health research needs are practical and nroblem oriented.  CHESS
research is thus pragmatic, and its goals are threefold:
   First, to evaluate existing environmental standards,
   Second, to quantitate pollutant burdens in exposed populations, and
   Third, to quantitate health benefits of pollutant control.

CHESS HISTORY AND OVERVIEW

Obligations to prepare air quality criteria documents end set air
quality standards were legislated by the Clean Air Act of 1967.  CHESS
evolution began the fiscal year of 1968 (FY68) with the health apprai-
sal of air quality standards (Figure 1).  The CHESS concept developed
simultaneously with the growth of a multidisciplinary "critical mass"
in FY 1969.  Growth for this single medium approach (air) was by
initial demonstration of both health indicators and ironitorinq within

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established areas, and their subsequent expansion into new areas (FY 1970-71)
The recent creation of the Environmental Protection Agency signalled a
more comprehensive and, now, multimedia approach to environmental hazards.
CHESS-will be fully operational to assess air pollution effects by FY 1973
and to assess multimedia toxic substances by FY 1975.  Present CHESS
operations consist of three basic, integrated functions; namely, Data
Collection, Bloenvironmental Measurements, and Information Synthesis,
supported by a fourth function, Research and Development and coordinated
by a fifth function, Program Management, (Figure 2).  Simultaneous environ-
mental  monitoring and measurement of sensitive health indicators in
community area sets are the fundamental CHESS components.

CHESS AREA SETS

CHESS area sets consist of groups of three or four communities representing
an exposure gradient for a pollutant, but similar 1n climate and socio-
economic traits.  Each community within an area set is a defined middle
class residential segment of a city containing three or four elementary
schools (500 - 1000 children per school) and often a secondary school.
CHESS pollutant gradients are as follows:
     A.  Particulate gradient with low S02 (3 Southeast cities)
     B.  S02 gradient with low particulates (Utah communities)
     C.  Combined S02 and particulate gradient (N. Y. City active,
         Chicago planned)
     D.  Photochemical oxidant gradient (Los Angeles Basin)
     E.  NOX gradient (Chattanooga)

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     F.  Trace element and S02 gradient (Western metal smelter
         communities)

CHESS EXPOSURE MONITORING

Neighborhood monitoring stations are sited to provide a representative
estimate of pollutant exposure for the study population.  Supplemental
home monitoring of tap water, household dust and soil samples permit even
more intimate estimates of environmental trace substance exposure.  Study
sub.iects usually live within a 1 to 1.5 mile radius of monitorina stations.
Topography, emission sources, and local land use are all considered when
placing stations.  The inlet of the monitoring instruments is usually
placed at head level and sheltered from uncommon proximate pollution
sources.  The CHESS System^ monitors for the following environmental
exposures:
     A.  Present CHESS system, all stations
         1.  Total  suspended particulates (daily)
             a.  Sulfates (daily)
             b.  Nitrates (daily)
             c.  Organic (monthly)
             d.  Benzapyrene (monthly)
             e.  Trace metals (monthly)
        2,   Respirable particulate (daily)
        3.   Dustfall (monthly)
            a.  Trace metals (monthly)
        4.   Sulfation - (Pb 02 monthly)
        5.   Twenty-four hour S02 (daily)

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     B.  Present system, some stations
         1. Two hour soiling index
         2.  Twenty-four hour N02
         3.  Continuous N02
         4.  Continuous S02
         5.  Continuous oxidants
     C.  CHESS - CHAMP:  Community Health Ambient Monitoring
         Program, prototype field testing.
         1.  Continuous NO-N02
         2.  Continuous SC"2
         3.  Continuous oxidants
         4.  Hydrocarbons
         5.  Mobile unit-replication
         6.  Wind speed and direction
                 »
CHESS - CHAMP (The Community Hea'ith Ambient Monitoring Program) is
currently collecting daily twenty-four hour samples and monthly samples for
gases and particulates at 30 environmental monitoring stations.  Real time
pollutant measurements can accurately relate short-term environmental
variations to acute response health indicators, distinguishing "peak"
exposure effects from 24 hour average effects.

Continuous monitors operate in some CHESS - CHAMP stations and a prototype,
automatic-data-acquisition, continuous monitoring station with magnetic tape
storage and "on call" telemetric output is now being field tested.  "On-call"
telemetry permits routine instrument performance checks, daily data
processing and thus immediate access* to data during air pollution episodes.

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Duplicate sampling of the environment and frequent calibration of all
instruments are systematically obtained to ensure accurate and consistent
instrument performance in the CHESS - CHAMP system.

CHESS HEALTH INDICATORS

Relationships between human diseases and pollution exposures  are neither
simple nor fully understood.  However, one may conveniently think of a
five stage biologic response spectrum of increasing severity:
(1) a tissue pollutant burden unassociated with other biological  changes,
(2) physiologic changes of uncertain significance, (3) physiologic disease
sentinels, (4) morbidity and (5) mortality (Figure 3).  CHESS  utilizes
health indicators which reflect this entire spectrum.  The following in-
dicators of acute and chronic responses are studied in community surveys
as well as in pre-enrolled panels of subjects.
     A.  Indicators of acute exposure (<24 hours)
      •
         1.  Reversible pulmonary function changes
         2.  Acute irritation symptoms
         3.  Frequency and severity of asthma attacks
         4.  Aggravation of chronic respiratory disease (CRD)  symptoms
         5.  Aggravation of cardiac symptoms
         6.  Daily mortality rates
     B.  Indicators of chronic exposure (>24 hours)
         1.  Pollutant burdens (man as an environmental dose  integrator)
         2.  Impairment of lung function
         3. . Absenteeism (no longer used)

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                                                                           6
         4.   Prevalence of chronic respiratory disease (CPD).
         5.   Frequency of lower respiratory disease (LRD).
         6.   Incidence of acute respiratory disease (ARD).
         7.   Mortality studies.
Comparison of similar groups is insured by obtaining covariate information
such as age, sex, race and smoking status.  These study desion covariates
all relate to morbidity; failure to measure and adjust for them could
cause serious confounding effects.  They are summarized as  follows:
     A.  Demographic - age, sex, ethnic groun, socioeconomic,status,
         reporting bias
     B.  Exposure - diet, drinking water, smoking habits, occupation,
         migration, indoor-outdoor gradients, daily movement
     C.  Special Risk - temporary such as age, pregnancy or illness;
         permanent such as alpha-1-antitrypsin deficiency or serum
         IgE levels.
          •
CHESS STUDY STRATEGIES

Selection of CHESS area sets and oollutant exposure gradients  were dic-
tated by the existence of air quality criteria documents for narticulate
matter, sulfur oxides, nitrogen oxides, ohotochemical oxidants, hydro-
carbons and carbon monoxide (CO), published by the National Air Pollution
Control Administration.  Area sets for individual oollutants were selected
from existing exposure monitoring data.  However, a CHESS set  to measure
the effects of exposure to CO was not established because short-term CO
effects are more precisely studied in controlled exposure chambers, and
long-term CO effects are likely to be confounded with the effects of
other  vehicle emissions  products.  Nor has an area set with a consistent CO

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gradient been found.

Middle class neighborhoods are chosen because they represent a larae
proportion of the population, have a more homogeneous family and social
class distribution, and are migrationally stable, thus providing a higher
likelihood of long-term participation.  Family participants in the surveys
for acute upper, acute lower, and chronic respiratory diseases and panels
for episodes are recruited from elementary school enrollments in CHESS
neighborhoods.  Subjects for the asthma, cardiac, and chronic respiratory
disease panels are obtained from prevalence survey results and from patient
listings of from private physicians.  As indicated, our broad data acquisition
techniques vary in the frequency and the type of response they measure.   The
following methods are currently used:
                 1.  Exposure monitoring
                 2.  Single-time questionnaire
                 3.  Weekly diaries
                 4.  Bi-weekly telephone contact
                 5.  Spirometry in schools
                 6.  Telephone contact during alerts
                 7.  Tissue collection
                 8.  Vital statistics

CHESS programs will operate from three to five years in selected areas.
Measurement of sensitive health indicators over a period of increased air
pollution control is an optimal way to quantitate the health benefits
of this control.

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CHESS data collection for FY 71  alone will  yield a total  of 40 x 106
health indicator and 3 x 105 air determination characters for data pro-
cessing (Table 1).  Rapid reporting is the  rule because high priorities
are placed on our study results.  Recent CHESS findings span the entire
biologic response spectrum and are outlined and referenced in Appendices
I and II.

Research goals are essential for optimal CHESS functioning and  play a
critical role in our development.  CHESS research and development goals
are threefold:  (1) to refine exposure monitoring, (2) to improve
statistical procedures and (3) to develop and test more sensitive health
indicators.  Current and future CHESS health-indicator research is
outlined in Appendix III.

Estimating environmental exposure-doses has always been a problem.  In
health studies of multimedia toxic substances, this problem increases.
Pollutant burden studies of biological accumulators such as pets, plants,
and wildlife in addition to humans should be utilized for appropriate
metals, pesticides, synthetic organic materials and selected gaseous pollutants.
Sample sets of tap water, housedust and soil from CHESS panel families
provide intimate information about trace metal exposure when coupled to
neighborhood environmental monitoring and dietary metal surveys.  Personal
monitors for all pollutants would permit the best pollutant dose estimates
for individual study subjects.

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We have addressed our remarks to the central questions of this conference,
namely, what pollutants to measure, what health indices to measure, avail-
able methods 4'f obtaining both types of data, and available study strategies.
CHESS permits a systematic, yet flexible, approach to these problems and has
already produced answers to some of them.

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Table 1.  FY 1971 CHESS Program - Data Collection Summary
Indicator
CRD
LRD
ARO
Pulmonary
Function
Asthma
Elderly
Irritation
Symptoms
Pollutant
Burdens
Frequency
biyearly
biyearly
biweekly
tri annually
weekly
weekly
tri annually
biyearly
Population
30 ,000
30,000
15,000
5,000
300
450
12,000
6,000

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                                 Morbidity
                                                        Adverse
                                                        Health
                                                        Effects
                           Physiologic Sentinels
                                of Disease
                           Physiologic Changes  of
                           Uncertain Significance
                             Pollutant Burdens
                       Proportion of Population  Affected
Figure 3    Human Biological  Response

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Appendix I  CHESS - Recent Findings

     A.  Pollutant burdens

         1.  Roadside gradients of Cd,  Pb and Zn £6]
         2.  As, Cd, Cu, Pb, Ag and Zn  in household dust [36]
         3.  Environmental exposure to  As, Cd and Pb reflected
             in hair and consistent over time and within
             individuals [19,20]
         4.  Hg in placentas, Cd in cord blood [35]
         5.  PCB highest *r\ urban whites [15]
         6.  Inter laboratory and interwash variation neglinible for
             hair Cd, Pb and Zn determinations [21]

     B.  Physiological changes of uncertain significance

         1.  Hair and blood Pb correlate (.40) over an exposure gradient [19]
         2.  Urinary Cd does not increase with age [18]
         3.  Eye irritation highly correlated with oxidant exnpsure [22]

     C.  Physiologic sentinels of disease

         1.  Pulmonary function in children decreased after S0x»
             particulate and NOX exposure [30,32,33]
         2.  Pulmonary function in adults decreased a"ter NOX  exposure [35]
         3.  Systolic BP in adults 40 may be increased after rd exposure,
             but not diastolic BP or cholesterol  [11]

     D.  Morbidity

         1.  ARD and LRD in children after exposure in MOX [25,32]
         2.  CRD symptoms in young adults but not adolescents  more  freouent
             after exposure to SO  and  parftculates but not 0   [35]
         3.  Respiratory and eye irritation symptoms induced fly
             acute urban air pollution  exposure [4]
         4.  Asthma attacks more frequent after nitrate, SOX,  and
             particulate exposure [3]
         5.  Cd not increased in toxemia of pregnancy [7]
         6.  No observed effect of chronic oxidant exposure on
             epidemic influenza in school children [26]
         7.  Epidemic!ogic evidence linking Cd to hypertension is weak
             when critically reviewed [18]

     E.  Mortality

         1.  No long term effect of As,  Pb on survival  of "P!eal  Conort" [24]
         2.  No long term effect of acute MOX exposure on survival  [17]
         3.  No effect of water hardness and no consistent effect of
            ' Cd on CVD mortality [27]

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    4.  Possible relationship between chronic urban air pollution
        exposure and carefully adjusted mortality rates in
        Chicago and Philadelphia 127]
    5.  Large temperature, influenza and socioeconomic effects
        on daily mortality [2]

F.  Associations with cigarette smoking

    1.  Increases in ARD, LRD freauency [14]
    2.  Higher influenza attack rates [16]
    3.  Impaired persistence of HI antibody [13]
    4.  Decreased ventilatory function
    5.  CRD symptoms in early adolescence
    6.  Refactiveness to acute air pollution episodes [4]
    7.  No change in ARD, influenza, or antibody persistence
        among children if parents smoke £10]

G.  Some Recent Reviews

    1.  General Overview of CHESS Research [29]
    2.  Overview of Human Pollutant Burden Research [12]
    3.  Air Pollution Episodes - Guide for Health Departments
        and Physicians [5]
    4.  Review of Arsenic Health Effects [1]
    5.  Review of Beryllium Health Effects [28]
    6.  Review of Cadmium Health Effects [18]
    7.  Reviews of Environmental Lead and Human Health [8,31]
    8.  Plasticizers in the Environment [23]
    9.  Environmental  Hazards of Optical  Brighteners [9]

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Appendix II  CHESS References
[1]  R. W. BUECHLEY, "The paths of arsenic pollution."  CRB  In-House
     Technical Report, September, 1970.
[2]  R. M. BUECHLEY, L. E. TRUPPI. J.  VAN BRUGGEN.  "Heat island -  death
     island," CRB In-House Technical  Report.  August,  1971.
     A. A. COHEN, S. M. BROMBERG, R.  W.  3UECHLEY,  L.  T.  HEIDERSCHEIT
     and C. M. SHY, "Asthma and air pollution from a  coal  fired power
     plant,"  American Journal and Public Health (in  press).
[4]  A. A. COHEN. C. J. NELSON  S.  M.  BROMBERG.  M.  PRAVDA  and  E.  F. FERRAND.
     "Symptom reporting during recent publicized and unpublicized  air
     pollution episodes,"  Abstract, 99th Annual APHA Meeting,  Minneapolis,
     October, 1971.
[5]  A. A. COHEN. C. M. SHY, F.  B.  BENSON. H.  B. RIGGAN.  V.  A.  NEWILL and
     J. F. FINKLEA, "Air pollution episodes  -  a  guide for health  departments
     and physicians,"  HSMHA Health Reports, 86(6):   537-550,  (June),  1971.
[6]  J. P. CREASON. 0.  McNULTY. L. T.  HEIDERSCHEIT.  D.  H. SWANSON and
     R. H. BUECHLEY, "Roadside gradients  in atmospheric concentrations  of
     cadmium, lead and zinc,"   Proceedings  of the  Fifth Annual  Conference
     on Trace Substances  in Environmental Health,  (in  press).
[7]  J. P. CREASON. J. F.  FINKLEA and  D.  I.  HAMMER,  "Relationship of
     cadmium to toxemia of pregnancy," In-house  Technical  Report,
     June, 1970.
[8]  R. E. ENGEL,  D. I. HAMMER.  R.  J.  M.  HORTON, N.  M.  LANE and L. A. PLUMLEE,
     "Environmental lead  and public health,"   EPA, Air Pollution Control
     Office Publication No.  AP-90.  March, 1971.

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 [9]  J. F. FINKLEA and K. BRIDBOP.D.  "Environmental  hazards  of optical
      brighteners," CRB In-house Technical  Report,  September,  1971.
[10]  J. F. FINKLEA,J. P. CREASON, D.  I.  HAMMER,  S.  M.  PROMPEPP  and
      W. B. RIGGAN. "Does cigarette smoking by parents  alter the  ARD
      immune response of ^heir children," Clinical  Research 19(2):"58,
      April, 1971.
[11]  J. F. FINKLEA. J. P. CREASON. S.  H. SANDIFER. J.  E.  KEIL, L.  F. PPIESTEP.
      D. I. HAMMER and W. B.  RIGPAM, "Cadmium exposure,  blood pressure  and
      cholesterol," Abstract, Clinical  Research,  Vol.  19 (1971),  pp.  313.
[12]  J. F. FINKLEA, D. I. HAMMER.  T. A.  HINNERS  and r.  PINKEPTON.  "Hum*n
      pol1utant burdens," American Chemical  Society Symposium on  the  Peter-
      mination of Air Quality,  ACS Meeting,  Los Angeles, Calif.  (1971),  (in  press)
[13]  J. F.  FINKLEA,  V. HASSELBLAD, H.  B.  RIGGAN,  H.  C.  NELSON, D.  I.  HAMMFP
      and \L  A.  NEHILL,  "Cigarette smoking  and  HI  response  to  influenza
      after natural  disease and immunization,"  Amer.  Rev. Resp.  Pis.
      (in press).
[14]  J.  F. FINKLEA. V.  HASSELBLAD.  S.  H. SANDIFFP. D.  I. HAMMER and
      G.  R.  LOWP.IMORE,  "Cigarette smokinq  and  acute  non-influenza  respirator"
      disease in military cadets," Amer. J.  Epid.  93(6):457-462, 1971.
[15]  J.  F.  FINKLEA,  L.  E.  PRIESTER,  J.  P. CREASON.  T.  HAUSEP  and  T.
      "Polychlorinated  biphenyl  residues  in human  plasma  expose  a
      urban pollution problem,"  Abstract,  99th Annual  APHA Meeting,
      Minneapolis,  October,  1971.

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[16]  J. F.  FINKLEA,  S.  H.  SANDIFER and D.  D.  SMITH.  "Cigarette  smrklna
      and epidemic influenza," Amer.  J.  Epid.  90:390-399,  1969.
[17]  K.  L..  GREGORY.  V.  F.  MALINOSKI  and C.  R.  SHARP.  "Cleveland  clinic
      fire survivorship study,  1929-1965,"  Arch.  Environ.  Health,  Vol.  18
      (1969), pp.  508-515.
[18]  £._ I. HAMMER.  J.F.  FINKLEA.  J.  P.  CREASON,  S.  H.  SPNDIFFP, J.  E.  KEIL.
      L. E.  PR1ESTER and J.  F.  STARA.  "Cadmium exposure and  human  health
      effects:   Some epidemiologic considerations,"  Proceedings  of the
      Fifth Annual  Conference on Trace Substances in Environmental  Health,
      (in press).
[19]  D. I. HAMMER, J.  F.  FINKLEA, R.  M.  HENDRICKS.  T.  A.  HINNFR5,  V.  P.
      RIGGAN and C.  M.  SHY,  "Trace metals in human hair as a  simple epidemio-
      logic monitor  of  environmental  exposure," Proceedings of the Fifth
      Annual Conference on Trace Substances in Environmental  Health,  (in press).
[20]  D. I. HAMMER,  J.  F.  FINKLEA, R.  M.  HENDRICKS,  C.  M.  SHY and  P.  J.  M.
      HORTON,  "Hair trace metal  levels and  environmental  exposure,"  flmer.
      J. Epid..  Vol.  93 (1971),  pp.  84-92.
[21]  D. I.  HAMMER. K.  NISHIYAMA.  M.  PISCATOR.  R.  P.  HENDRICKS,  J.  P.  CRFISPN
      and T. HINNERS. "Cadmium,  lead and zinc in hair  - effects  of environ-
      mental  exposure,  wash techniaues and laboratory error,"  Abstract,
      99th Annual  APHA  Meeting,  Minneapolis,  October, 1971.
[22]  D.  I. HAMMER, B.  PORTNOY.  P.  F.  HEHPLE, V.  HASSELRLAD, C.  P.  SH/'PP
      and P.  J.  M.  HORTON.  " A prospective dose-response  study  of  eye
      discomfort and photochemical  oxidants,"  Abstract,  99th Annual  APHft
      Meeting.  Minneapolis,  October,  1971.
[23]  T.  R.  HAUSER, "Plasticizers in  the environment,"  CRP In-house
      Technical  Report, April,  1971.

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[24]  W. C. NELSON, M.  H.  LYKINS,  V.  A.  NEWILL.  J.  F.  FINKLEA  and  P.  I.  HAMMER.
      "Mortality among orchard workers exposed to  lead  arsenate  spray:  A
      cohort study."  DHER  In-House Technical  Reoort. 1970.
[25]  M. E.  PEARLMAN. J.  F. FINKLEA,  J.  P.  CRFASON,  C.M.  SHY, M.  M.  YPUNP
      and R.  J.  M.  MORTON.  "Nitrogen dioxide and lower respiratory  illness,"
      Pediatrics,  Vol.  47 (1971),  pp.  391-398.
[26]  M^E.  PEARLMAN,  J.  F.  FINKLEA,  C.  M.  SHY,  J.  VAN  BRUGGEN  and  V.  A.  NEWIL_L_,
      "Chronic oxidant exposure and  epidemic  influenza,"  Environmental
      Research, Vol.  4 (1971),  pp.  129-140.
[27]  C.  PINKERTON.  J.  P. CREASON,  C.M.  SHY,  D.  I.  HAMMER,  R. V.  BI'ECHLFY
      and G.  K.  MURTHY,"   Cadmium content of milk  and  cardiovascular  disease
      mortality," Proceedings of the 5th Annual  Conference  on Trace  Substances
      in Environmental  Health, (in press).
[28]  C. R.  SHARP,  "Beryllium - A hazardous air pollutant," CRB  In-house
      Technica1  Report.  June,  1971.
[29]  C.  M. SHY, J.  F. FINKLEA.  D.  C.  CALAFIORE,  F.  B.  BENSON.  W.  C.  NELSPN
      and V.  A.  NEWILL,  "A program of community health  and  environmental
      surveillance (CHESS),"  American Chemical  Society  Symposium on  the
      Determination of Air Quality, ACS  Meeting,  April  1,  1971, Los  Angeles
      (in press).
[30]  C.  M.  SHY, J. P. CREASON,  M. E. PEARLMAN. K.  E. McCLAIN. F.  B.  BENSON
     -and M.  M.  YOUNG.  "The Chattanooga  school  children  study  1:   Methods,
      description of pollution  exposure  and  results  of  ventilatory function
      testing," J. Air Poll.  Control  Assoc.  Vol.  20  (1970),  pp.  539-545.

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 [31]  C. M. SHY. D. I. HAMMER. H. E. GOLDBERG, V. A. NEHILL and W.  C.  NELSON,
      "Health hazards of environmental lead," CRB In-house Technical  Report.
      March, 1971, (to be published).
[32]  C. M. SHY. V. HASSELBLAD, R. M. BURTON, A.  A.  COHEN and MIMI  PRAVDA.
      "Is air pollution in New York City associated with decreased  venti-
      latory function in children," Abstract 99th Annual  APHA  Meeting.
      Minneapolis, October, 1971.
[33]  C. M. SHY. C. J.  NELSON.  F.  B. BENSON. W.  B.  RIGGAN and  V. A.  NEPILL,
      "The Cincinnati school  children study:   Effect  of  atmospheric  particu-
      lates and sulfur dioxide on ventilatory performance  in children,"
      Amer. J.  Epid.. (in press).
[34]  W.  B. RIGGAN.  R.  W.  BUECHLEY,  J.  B. VAN BRUBGEN, C.  R. SHARP.  L. TRUPPI,
      W.  C. NELSON and V.  A.  NEV'ILL.  "Daily mortality predictor models: A
      tool  for  environmental  assessment and pollution control," Abstract.
      99th  Annual  APHA  Meeting, Minneapolis,  October, 1971.
[35]  Division of Health Effects Research,  Unpublished  data.
[36]  Hammer, D.I., Finklea,  J.F., Bridbord,  K.,  Pinkerton, C.,  Hinners,  H.A.
      and Creason, J.P.  Household dust as  an index of  environmental trace
      substance exposure I, Preliminary Report,  Presented  at  the meeting
      of the Subcommittee on  the Toxicology,  International Conference of
      the Permanent Commission and International  Association  on  Occupational
      Health, Slanchev Bryag, 20-24 September, 1971,  Bulgaria (to be pub-
      lished).

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1.^'.',  ;,II „,..).!_ 2  60603

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Appendix III  CHESS - Research and Development Goals
     A.  Refined Exposure Monitoring
         1.  Biological  amplifiers (pets, plants, wildlife)
         2.  Personal monitors
         3.  Tap water,  housedust, soil
     B.  Improved Statistical  Procedures
         1.  Hockey-stick and other dose-response functions
         2.  Ridit transformation and linear models for categorical  data
         3.  Daily mortality models
         4.  Analyses of truncated and censored data
         5.  Estimating  personal  exposure
         6.  Multivariate techniques for repeated measurements
         7.  Health information synthesis system
     C,  More Sensitive  Health Indicators
         1.  Pollutant burdens
             a.  Maternal-fetal tissue sets
             b.  Patients - biopsy, surgery, autopsy
             c.  Special occupations
         2.  Altered physiology of uncertain significance
             a.  Carboxyhemoglobin
             b.  RBC fragility and survival
         3.  Physiologic heralds  of disease
             a.  Other PF tests
             b.  Blood lipid patterns
             c.  Blood pressure
             ci.  Immune  response
             e.  Exfolliative cytology
         4.  Morbidity
             a.  Aggravation of hypertension
             b.  Aggravation of RDS of Newborn
                                     t
         5.  Mortality
             a.  CO and  coronary  disease
             b-  Area studies  linked to  SS  records

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